Od ranije je poznato kako ucestalost ekspanzivnih lezija nadbubrežnih žlijezda na obdukcijama znacajno nadilazi broj klinicki potvrđenih adrenal

Sažetak.Od ranije je poznato kako učestalost ekspanzivnih lezija nadbubrežnih žlijezda na obdukcijama značajno nadilazi broj klinički potvrđenih adrenalnih lezija.Zbog sve učestalijeg korištenja slojevnih tehnika snimanja posljednjih godina otkriva se značajno veći broj suprarenalnih tvorbi koje zahtijevaju karakterizaciju i endokrinološku obradu.Većina tih lezija su nefunkcionalni (silentni) adenomi, tzv.incidentalomi, no potrebna je slikovna karakterizacija lezija

Background: An aneurysm of the superior mesenteric artery (SMA) with a diameter of 2.2 cm was found incidentally on an ultrasound (US) examination in a 26-year-old woman. The only known risk factor was an intracranial aneurysm that was found on her grandmother's autopsy. Based on pregnancy planning and the current literature, endovascular management with a covered stent was proposed.Case Report: Self-expandable, covered stent (Bard, Fluency (R)) was implanted using a single transfemoral approach. A stiff guidewire and a large sheath distorted the anatomy, which resulted in an incomplete aneurysmal neck covering. In the absence of additional covered stents, the procedure was terminated. Two weeks later, computed tomographic angiography (CTA) confirmed persistent aneurysmal perfusion due to the incomplete neck coverage. A multidisciplinary board opted for a second endovascular attempt, this time with a longer covered stent via the transaxillary approach in order to reduce anatomical distortion. Balloon, expandable, cobalt-chrome covered stent (Jotec, E-ventus BX (R)) was implanted in the SMA, covering the aneurysmal neck and overlapping the previously implanted covered stent. Angiography confirmed a complete exclusion of the aneurysm. A control US performed three weeks later confirmed a patent covered stent and complete aneurysmal exclusion. There was a mild median nerve damage periprocedurally that resolved in three months. The most recent US control examination, performed eleven months after the procedure, showed an excluded aneurysm and a patent covered stent. There were no clinical signs of bowel ischaemia during the follow-up period.Conclusions: Endovascular management of SMAA proved to be safe and efficient. The "access from above" is probably safer and should be considered in the majority of cases with acceptable sizes of access vessels. Mid-term results in our patient are good and life-long follow-up is planned to prevent late complications.

Aim: Rare patients with advanced hepatocellular carcinoma (HCC) exclusively present with symptoms of distant metastasis. If there is no histological confirmation of the disease from liver tissue sample, extrahepatic lesion biopsy can confirm or exclude clinical suspicion. Case report: A 57-year-old male with long history of hepatitis C infection underwent computed tomography (CT) and magnetic resonance (MR) imaging which revealed nodular liver rearrangement with thrombosis of the right portal vein branch. Large intrahepatic HCC with vascular invasion was suspected, although without clear demarcation on imaging or histological verification. Only severe cirrhosis was found in several biopsy specimens. Since the patient suffered from simultaneous chronic lower back pain, and paresthesia with incontinence emerged, he underwent pelvic MR which demonstrated osteolitic destruction and large soft tissue mass in the sacrum. CT-guided biopsy confirmed HCC metastasis. Supraselective embolization of irrigating lateral sacral arteries was performed. Conclusion: Diagnosis of HCC sometimes can be challenging despite diagnostic procedures performed in accordance with current guidelines. In our patient sacral lesion was the only detectable metastasis of HCC and the target for histological confirmation of the disease. In patient with clinical suspicion on HCC but without histological confirmation from liver tissue, detection and biopsy of distant metastases is the only way to diagnose the disease.

Svrha. Prikaz timskog pristupa u lijecenju bolesnika s malfunkcijom arteriovenske (AV) fistule za hemodijalizu i rezultata klinickog pracenja u prvih sest mjeseci. Ispitanici i metode: deset bolesnika s malfunkcijom AV fistule prezentirano je multidisciplinarnom timu koji obuhvaca nefrologa, radiologa i urologa. Klinicke manifestacije bile su nedostatan protok krvi i / ili visoki venski otpor na hemodijalizi, zgrusavajne krvi u vantjelesnom krvotoku, duže krvarenje nakon punkcije, bolovi u ruci, otok ruke ili nesazrijevanje AV fistule. U svih bolesnika ucinjen je angiografski pregled s neposrednim endovaskularnim zahvatom, ako je bio indiciran, i hemodijalizom. Rezultati: Angiografski pregled je pokazao razlicitost patologije arterijskog i venskog segmenta. U vecine bolesnika klinicki ishod je bio uspjesan uz dobar protok krvi na postupcima hemodijalize koji su bili urednog tijeka. Zakljucak: Iako je broj ispitanika relativno malen, postigli smo znacajan klinicki uspjeh kao rezultat uspjesne suradnje clanova multidisciplinarnog tima.

Aim: To present team approach in resolving arteriovenous (AV) fistula malfunction in patients on chronic hemodialysis and our results during the six months follow-up. Patients and methods: Ten patients with AV fistula malfunction were presented to our multidisciplinary team, that includes a nephrologist, radiolgist and urologist. Clinical manifestations were inadequate blood flow rate and / or high venous pressure during dialysis, blood clotting in the extracorporal circuit, longer bleeding after puncture, pain in the arm, arm sweeling or non-maturation of AV fistula. In all patients fistulography was performed with immediate endovascular therapy and dialysis, if applicable. Results: Fistulography showed a variety of pathological findings in arterial and venous segments. In the majority of patients the clinical outcome was successful, allowing a much higher blood flow rate and successful dialytic treatment. Conclusions: Although the patient group was small, we observed significant clinical benefits as a result of close team-work between different specialities.

Prikazani su rezultati uspjesne suradnje multidisciplinarnog tima u lijecenju bolesnika s malfunkcijom arteriovenske fistule za hemodijalizu.

UVOD. Karcinom bubrega (KB) je po ucestalosti 13. karcinom među svim malignim oboljenjima. Koristenje suvremenih dijagnostickih metoda dovelo je do porasta broja novootkrivenih bolesnika s KB. Osnovni cilj dijagnostickih metoda kod bolesnika s bubrežnom lezijom je ispravna diferencijalna dijagnoza između benignih i malignih bubrežnih stanja. Tradicionalno, ultrazvuk (UTZ) je prva dijagnosticka metoda koja se koristi u dijagnostici bubrežnih oboljenja. Kompjutorizirana tomografija (CT) je metoda izbora u klasificiranju bubrežnih lezija, pogotovo cisticnih. Prikazati cemo tri bolesnika s tumorskom patologijom bubrega koja je potpuno drukcije prikazana od strane UTZ i CT. PACIJENTI I METODE. Od 1. sijecnja 2010. godine do 31. svibnja 2013. godine na Klinici za urologiju, KBC Rijeka u 185 bolesnika je ucinjena nefrektomija zbog KB. U svih bolesnika ucinili smo prije operacije UTZ i CT. U tri bolesnika smo zamijetili znacajno nepodudaranje između ove dvije dijagnosticke metode. REZULTATI. U tri bolesnika UTZ je pokazao da se radi o fokalnoj, solidnoj bubrežnoj promjeni, ali je CT govorio u prilog cisticne lezije (Bosniak II-III). S obzirom na znacajnu nepodudarnost ucinjena je ultrazvucno vođena biopsija bubrega. U svih bolesnika biopsijom je dijagnosticiran KB te je ucinjena nefrektomija. Svi bolesnici su makroskopski imali solidni KB bez cisticne komponente. Mikroskopski sva tri bolesnika su imali papilarni podtip KB (tip I – 2 bolesnika, tip II – 1 bolesnik). Dva bolesnika su imali stadij pT1a i jedan pT1b. Poslijeoperacijski tijek je bio bez osobitosti u svih bolesnika. ZAKLJUCAK. Senzitivnost razlicitih dijagnostickih metoda u otkrivanju KB je: 67% za intravensku urografiju (uz nisku specificnost), 79% za UTZ, 94% za konvencionalni CT te 95-100% za spiralni CT (specificnost 88-95%). CT je u vecine bolesnika najsenzitivnija metoda u klasificiranju bubrežnih lezija. U bolesnika kod kojih UTZ upucuje na solidnu leziju, unatoc nalazu CT-a da se radi o cisticnoj, neophodno je uciniti biopsiju bubrega. Misljenja smo da se obje dijagnosticke metode moraju komplementarno nadopunjavati u dijagnosticiranju bubrežnih lezija.

We report a case of ureterolithiasis in a patient with an en bloc kidney transplantation, using extracorporeal shockwave lithotripsy (ESWL). The patient presented with asymptomatic macrohematuria. Computed tomography revealed a ureteral calculus just below the pyeloureteral junction with hydronephrosis of the medially positioned kidney. Took two sessions of ESWL were required for complete disintegration of the stone. At 3 years after successful treatment, the patient has an excellent functioning and stone-free graft.

Carotid artery stenting (CAS) is a widely used method in prevention of stroke for carotid artery stenosis as an alternative to surgical treatment. Initial studies reveal higher morbidity and mortality rates for CAS than acceptable standards for carotid endarterectomy (CEA). The aim of this study was to compare results in a series of CAS with concurrent risk-matched group of CEA patients. The study included two groups of 50 patients with internal carotid artery stenosis. We compared early outcome (30 days after procedure) in risk-matched groups of patients that underwent these procedures. Post procedural complications were equally frequent in both groups. There was no significant difference in perioperative complication rates (P = 0.871). Comparison of these two methods shows that CAS and CEA are competitive methods for treatment of carotid artery stenosis. Particularly in symptomatic patients with high risk for surgery CAS is alternative treatment.

Multiple randomized trials over the last decade for both symptomatic and asymptomatic carotid stenosis have proven the efficacy of carotid endarterectomy (CEA) in reducing the risk of stroke. The aim of this prospective non-randomizing cohort study was to determine the incidence of carotid arteries restenosis after CEA as well as to ascertain the clinical and etiological characteristics for the development of restenosis. Treatment data from 178 KBC Rijeka patients that had undergone CEA in the period 1. 09. 2005-30. 8. 2009 has been processed. All patients are monitored trough our Neurosonology laboratory algorythm--first Doppler ultrasound examination within the first week after CEA and the following after 1, 3, 6 and 12 months. After this time once a years. The average monitoring time was 21 month (1-36 months). In the stated period 27 restenosis was diagnosed (15.16%). Only four of them were symptomatic (14.81%). Patient survival rate is 98% in the first 12 and 92% in the first 36 months. Carotid restenosis is usually asymptomatic. Non-invasive postoperative carotid arteries color Doppler screening is essential in the early identification of patients with the risk for the development of restenosis.

We present a case of spontaneous recanalization of the internal carotid artery (ICA) that occurred in a 51-year-old male patient. The occlusion of the right ICA was asymptomatic and was detected incidentally during imaging of the opposite carotid artery. The patient underwent neuroradiologic analysis and a tapered, flame-like occlusion suggestive of the right ICA dissection was detected. One month later, a carotid Doppler ultrasound demonstrated patent right carotid artery with normal spectral flow. Five-month follow-up showed that the ICA remained patent.

AIMS:Renal arterial pseudoaneurysm is a rare complication of renal transplantation that often causes a graft loss. A recent successful outcome of the operative treatment and a reappearance of a pseudoaneurysm and a possibility of watchful followup of pseudoaneurysm encouraged us to present our modest experience with pseudoaneurysm after renal transplant.MATERIAL AND METHODS:In our series of 843 renal transplants performed during 37 years vascular complications were observed in 57 (6.76%) patients. Pseudoaneurysm occurred in three patients (0.35%). The first pseudoaneurysm was found in 1973. A 23-year-old male patient received a double renal artery kidney from HLA identical brother. The upper renal artery was anastomosed by an end-to-end way with the internal iliac artery, and and the lower renal artery by end-to-side way to the external iliac artery. Five weeks after transplant an arteriography was performed because of the bruits heard over the transplant. A 15 x 10-mm pseudoaneurysm was revealed on the end-to-end anastomosis between internal iliac and upper renal artery. Six weeks after transplant a renal arterial resection and an end-to-side anastomosis between renal artery and common iliac artery was performed. The 38-year-old male patient received his second transplant from a 17-year-old female donor dead after craniocerebral trauma in December 2004. Two renal arteries were anastomosed separately with external iliac artery using aortic patches. Two and half moths after transplant he was admitted for an increase of creatinine level and hypertension. Color Doppler, dynamic scintigraphy and an angiography revealed a 20 x 1,3 mm aneurysmatic formation at the anastomosis of upper renal artery. The flow in the belonging part of the transplant was reduced. At surgical intervention a saphenous vein graft between internal iliac artery and renal artery was performed. Ischemia time was 15 min. The pseudoaneurysm was removed. A hole on external iliac artery was closed with a saphenal patch. The 38-year-old female patient received her second transplant in January 2005 from cadaver. There were 3 arteries. The upper polar arterywas first anastomosed to principal renal artery Then both arteries were anastomosed to external iliac artery termino-laterally.RESULTS:In the first patient a lesion of the ureteral anastomosis caused an infection, thrombosis of lower artery and a graft loss 4 months and half after transplant. The second patient was admitted urgently 3.5 months after the repair of his pseudoaneurysm because of the pain in the pelvic region. He was working that day during several hours in sitting position on his terrace. Immediate examination with color Doppler revealed a large 6 x 7-cm pseudoaneurysm medially of the transplant. An arteriography demonstrated a pseudoaneurysm with a blood leakage most likely at the site of the closure of external iliac artery with a saphenal vein patch. The arteriography showed a slower and diminished blood flow in the lower part of the transplant. At intervention the pseudoaneurysm was removed. The external iliac artery was considerably damaged and replaced with Goretex prostesis 6 mm. Unfortunately the transplant lower artery could not be saved. A microbiological examination of pseudoaneurysm in both patients was negative. In the third case we chose a watchful follow-up. Last Doppler controls show reduction of psudoaneurysm.DISCUSSION AND CONCLUSIONS:The development of a pseudoaneurysm of a transplant artery is very rare complication. Since actually ultrasonography is routinely used, a pseudoaneurysm can be easily detected. Color Doppler allows a differential diagnosis from hematoma, urinoma and lymphocele. Unfortunately a pseudoaneurysm after renal transplant often causes a loss of the transplant. The first patient had successful resection of a pseudoaneurysm, but the transplant was lost because of infection. The other patient had a subsequent pseudoaneurysm after the repair of the first. Unfortunately its repair caused an exclusion of the lower part of the kidney, but the residual renal function is satisfactory. In the third patient we chose a follow-up aware that each intervention could cause a graft loss.

Study objectives: Although spontaneous recanalisation of occluded internal carotid arteries ACI/ has been previously observed and reported, the exact mechanisms including incidence were insufficiently studied. The reason for this is that diagnosis of recanalisation required a conventional catheter angiography, a “gold standard” as well as an invasive procedure for distinguishing total arterial occlusion from sub- occlusion. The exact timing of spontaneous recanalisation remains unclear, although it has most commonly occurred early after a stroke. In addition and although unclear, several mechanisms, including vasospasm, distal embolisation of occlusive clot, and spontaneous clot lysis, have been proposed to explain recanalisation Methods: We present two cases of late spontaneous recanalisation of an acute occluded internal carotid artery, angiographically reported in the Department of neurology Clinical Hospital of Rijeka. Results: Routine follow-up in both cases has shown spontaneous recanalisation of internal carotid artery after which we scheduled both patients for stenting. Conclusion: These and other similar cases described in literature as well as limited usage of angiography in control diagnosis, raise the possibility that the recanalisation in ACI/ is more frequent than previously considered. Noninvasive ultrasound diagnostic is a safe and secure method to be used in proving significant carotid disease. Routine follow – up and serial monitoring of all patients with carotid occlusion is required, especially because of known progression of atherosclerosis in asymptomatic carotid arteries after contralateral endarterectomy intervention. During this time it is possible to determine which patient is to undergo a successful surgical or stenting procedure, and help determine true incidence of recanalisation, in despite of the ambiguity of the recanalisation mechanism. Although both of our patients were treated with low density heparin from the onset, it is not known which role, if any, the anti-platelet and anticoagulant therapy may have in the treatment process of recanalisation. Diagnosing spontaneous recanalisation of occluded extracranical ACI seems to be more frequent than expected bur the mechanism of this phenomenon and an implication is still truly unkonwn.